How Leading Providers Optimized Their RCM Performance

Background

This regional health system, comprising four hospitals and over 50 clinics, struggled with inefficient pre-service processes that contributed to high claim denial rates and extended revenue cycle times. Patient access staff often gathered incomplete or inaccurate demographic and insurance information, leading to downstream issues with claim submission and reimbursement.

The Transformation Journey

To address these challenges, the health system embarked on a comprehensive pre-service optimization initiative. First, they implemented a robust patient estimation and pre-registration solution, enabling patients to securely provide their demographic and insurance details online before their appointments. This information was then verified and updated in real-time through integration with multiple payer databases.

Next, the organization invested in staff training and standardized scripting to ensure consistent and accurate data collection during in-person registrations. They also adopted advanced propensity-to-pay scoring models to identify potential financial risks upfront and facilitate proactive financial counseling and payment plan discussions with patients.

Results and Impact

Within 12 months of implementing these changes, the health system witnessed remarkable improvements in their pre-service processes:

• Clean claim rate increased from 82% to 94%
• Denial rate dropped from 12% to 4%
• Point-of-service cash collections grew by 28%
• Days in accounts receivable (A/R) decreased from 55 to 42 days

By streamlining pre-service processes and enhancing data integrity, the health system not only reduced administrative overhead and rework but also improved patient satisfaction by minimizing billing issues and collection efforts.

Background

An academic medical center with a renowned cancer treatment program faced challenges in accurately capturing and coding complex oncology services. Inadequate charge capture processes and coding inconsistencies resulted in significant revenue leakage and a high volume of denied claims, straining the organization’s financial performance.

The Transformation Journey

To tackle this issue, the medical center established a dedicated coding and charge capture task force comprising clinical, billing, and revenue cycle experts. This cross-functional team conducted a comprehensive review of existing workflows, charge capture tools, and coding resources.

Based on their findings, the organization implemented several key initiatives:

1. Charge capture automation: They integrated their electronic health record (EHR) system with advanced charge capture solutions, automating the process of identifying and capturing billable services based on clinical documentation.
2. Coding education and audits: The medical center invested in ongoing coding education programs for their clinical and billing staff, ensuring a deep understanding of the latest coding guidelines and requirements. They also implemented regular coding audits to identify and address coding discrepancies proactively.
3. Clinical documentation improvement: In collaboration with physicians and clinicians, the task force developed standardized documentation templates and workflows to capture the necessary clinical details for accurate coding and billing of oncology services.

Results and Impact

Within 18 months of implementing these initiatives, the academic medical center achieved the following results:

• Charge capture rate increased from 78% to 95%
• Coding accuracy improved from 85% to 97%
• Denial rate for oncology services decreased from 18% to 6%
• Net revenue for oncology services grew by 24%

By optimizing coding and charge capture processes, the medical center not only maximized appropriate reimbursement but also reduced administrative burdens on clinical staff, allowing them to focus more on patient care.

Background

A large multi-specialty physician group, with over 500 providers across 20 locations, struggled with a high volume of denied claims and inefficient denial management processes. Denials were often not identified or worked in a timely manner, leading to extended accounts receivable cycles and substantial revenue leakage.

The Transformation Journey

To address this challenge, the physician group embarked on a comprehensive denial management overhaul. They began by implementing advanced denial tracking and analytics solutions, enabling them to identify denial trends, root causes, and high-impact denial categories.

Based on these insights, the group developed targeted action plans to address the most significant denial drivers.

This included:

1. Payer contract analysis: The group conducted a thorough review of their payer contracts to ensure alignment between coding and billing practices and payer-specific requirements.
2. Denial prevention strategies: They implemented front-end denial prevention measures, such as automated claim scrubbing and enhanced eligibility verification processes, to catch and correct issues before claims were submitted.
3. Denial management workflows: The group established dedicated denial management teams and streamlined workflows for timely identification, investigation, and resolution of denied claims.
4. Staff training and education: They invested in ongoing staff training programs to enhance understanding of payer policies, coding requirements, and denial management best practices.

Results and Impact

Within 24 months of implementing these initiatives, the multi-specialty physician group achieved impressive results:

• Initial denial rate decreased from 18% to 7%
• Denial write-offs reduced by 42%
• Days in accounts receivable (A/R) decreased from 62 to 48 days
• Net collection ratio improved from 92% to 96%

By proactively addressing denial root causes and implementing efficient denial management processes, the physician group not only improved revenue recovery but also reduced administrative overhead and associated costs.

Background

An integrated delivery network, comprising three hospitals and numerous ambulatory care facilities, faced challenges in managing patient financial responsibilities effectively. With increasing patient payment obligations due to rising deductibles and coinsurance, the network experienced high levels of bad debt and extended collection cycles, impacting overall revenue performance.

The Transformation Journey

To address these challenges, the delivery network embarked on a comprehensive patient financial engagement strategy. They began by implementing user-friendly online patient estimation and payment tools, enabling patients to understand their out-of-pocket costs upfront and make payments conveniently before or after their visits.

The network also revamped its patient financial counseling processes, training staff to have transparent conversations with patients about their financial responsibilities and available payment options. They adopted propensity-to-pay scoring models to identify high-risk accounts proactively and offer tailored financial assistance and payment plans.

To streamline collections, the delivery network implemented an omnichannel billing and payment platform, allowing patients to receive consolidated statements and make payments through their preferred channels (online, mobile, IVR, etc.). They also partnered with external collection agencies and deployed advanced analytics to optimize collection strategies and reduce bad debt write-offs.

Results and Impact

Within 18 months of implementing these patient financial engagement initiatives, the integrated delivery network achieved the following results:

• Point-of-service collections increased by 35%
• Bad debt write-offs decreased by 28%
• Days in accounts receivable (A/R) reduced from 65 to 52 days
• Net patient revenue grew by 16%

By empowering patients with transparent financial information, flexible payment options, and proactive financial counseling, the delivery network not only improved revenue performance but also enhanced patient satisfaction and loyalty.